Provider Demographics
NPI:1528213931
Name:DERJAN GROUP
Entity Type:Organization
Organization Name:DERJAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-831-3919
Mailing Address - Street 1:801 SHADOWBERRY CRST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3544
Mailing Address - Country:US
Mailing Address - Phone:757-831-3919
Mailing Address - Fax:
Practice Address - Street 1:550 NORTH BATTLEFIELD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3544
Practice Address - Country:US
Practice Address - Phone:757-831-3919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305R00000X305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization